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NO LONGER GOING WITH THE FLOW TIME TO CHANGE COURSE MID-STREAM

NO LONGER GOING WITH THE FLOW TIME TO CHANGE COURSE MID-STREAM. Richard B (Tom) Thomson Jr PhD D(ABMM) FAAM NorthShore University HealthSystem The University of Chicago Pritzker School of Medicine rthomson@northshore.org. Urinary Tract Infection. UTI in general

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NO LONGER GOING WITH THE FLOW TIME TO CHANGE COURSE MID-STREAM

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  1. NO LONGER GOING WITH THE FLOWTIME TO CHANGE COURSE MID-STREAM Richard B (Tom) Thomson Jr PhD D(ABMM) FAAM NorthShore University HealthSystem The University of Chicago Pritzker School of Medicine rthomson@northshore.org

  2. Urinary Tract Infection • UTI in general • 1 in 3 females are treated for UTI by age 23 • 50% of females have UTI during lifetime • Cost of community UTI > 1.5 billion $ / yr • Nosocomial UTI • 30% of HAIs reported to NHSN • >560,000 nosocomial UTI/year to NHSN with 13,000 deaths • Cost approx 0.5 billion/yr • 15-25% hospitalized patients catheterized • 75% HA UTI related to catheterization http://www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

  3. Case • 65 yo female admitted for surgery to repair a pseudoaneurysm (femoral artery) • PMH includes dilated cardiomyopathy, atrial fibrillation, surgery for an inguinal abscess • One day post-op bladder catheter removed, urine sent to lab to “make sure there was no infection” • Dysuria, temp 100 F, macroscopic UA negative • Culture 10-50,000 E. aerogenes • Treated with ciprofloxacin for 10 days

  4. The Urine Culture in Complicated Urinary Tract Infection • OBJECTIVES • When to collect a specimen • How to collect a specimen • Use of the UA • Reporting culture results • Interpretation of culture results • What the laboratory can do to improve the urine culture

  5. When to Collect a Urine Specimen • The diagnosis of UTI requires the detection of a pathogen in a patient with appropriate clinical findings • Examples of Clinical Findings • Symptoms: Dysuria, frequency, urgency, suprapubic or flank pain • Signs: Fever, leukocytosis • When not to Collect • In the absence of clinical findings • When patient has indwelling catheter • Following catheter removal • Urine is foul smelling • Detect asymptomatic bacteriuria • Pregnancy and prior to urologic surgery

  6. When to Collect a Urine Specimen • 84 y patient from nursing home admitted to hospital with 3 d hx of confusion and dehydration • PMH includes heart diseaseand pneumonia • Clinical findings include: • Confusion, unable to answer questions • No fever or leukocytosis • Urine is cloudy • UA shows squam’s, protein, trace LE, casts, bacteria • Urine and blood specimens sent for culture • R/O pneumonia and UTI • Antibiotics administered

  7. How to Collect a Urine Specimen • Clean-catch midstream – Needed? • Midstream – help with collection • Straight (in/out)catheter - Best • Supra-pubic aspiration – Gold Standard?? • Foley/supra-pubic catheter – Always Positive • Urine collected during cystoscopy - Anaerobes

  8. How to Use the UA • Macroscopic dipstick v Microscopic UA • Associated with UTI • Leukocytes (> 10/mm3uncentrifuged or > 5-10 per HPF sediment), nitrites, macroscopic blood • Fair sensitivity and poor specificity • Poor predictor of UTI • Detecting bacteria in the wet mount of spun sediment • Odor/turbidity • UA with reflex culture when UA is positive • Patients with a negative UA and symptoms of UTI should have a urine culture • 50% patients with asymptomatic bacteriuria do not have leukocytes in urine

  9. Reporting Culture Results • It all started with: • Kass. 1956. Asymptomatic Infections of the Urinary Tract. Trans. Assoc. Am. Physicians. 69:56-64.

  10. Reporting Culture Results • It was complicated by: • Stamm et al. 1982. Diagnosis of ColiformInfectin in Acutely Dysuric Women. N.E.J.M. 307:463-8

  11. Reporting Culture Results • Women Acute Cystitis> 102 CFU/ml • Stamm et al. 1982. NEJM 307:463-8 • Men Acute Cystitis> 103 CFU/ml • Lipsky et al. 1987. JID 155:847-54 • Pyleonephritis> 105 CFU/ml • Kass. 1956. Trans Assoc Am Physicians 69:56-64. • UTI in Catheterized Patient ??102->105 CFU/ml • Stark and Maki. 1984. NEJM 311:560-4 • Asymptomatic Bacteriuria> 105 CFU/ml x 2 • Kass. 1956. Trans Assoc Am Physicians 69:56-64 • UTI in the Infant 2-24 mo> 5x104 CFU/ml-cath • Subcommittee on UTI. 2011. Pediatrics 128:595-611

  12. Laboratory Reporting Culture Results • What’s the Problem? • How much clinical information does the laboratory have when reporting the colony count? • How well do clinicians understand the importance of urine colony counts when interpreting results? • How reliable and useful are UA results? • What are the consequences of misreporting or misinterpreting urine culture results? • What can the laboratory do?

  13. Case • 65 yo female admitted for surgery to repair a pseudoaneurysm (femoral artery) • PMH includes dilated cardiomyopathy, atrial fibrillation, surgery for an inguinal abscess • One day post-op bladder catheter removed, urine sent to lab to “make sure there was no infection” • Dysuria, temp 100 F, macroscopic UA negative • Culture 10-50,000 E. aerogenes • Treated with ciprofloxacin for 10 days

  14. How Much Clinical Information Does the Laboratory Have? • Patient age and location • Midstream, catheter, cystoscopy?? • HIS data? • Not much, especially when reviewing 100’s of urine cultures each day

  15. Urinary Tract Infection

  16. How Well do Clinicians Understand Urine Colony Counts • > 105 CFU/ml for everyone • Most treat any number if patient has “soft” clinical finding • Some treat any number regardless of clinical findings because antimicrobials were started by someone else • 47% of 185 sequential patients with presumed UTI did not have UTI • Kwon et al. 2012. Am J Clin Path 137:778-84

  17. How Useful is the UA? Elderly ED Patients with and without Symptoms of UTI Positive Culture = > 100,000 cfu/ml Positive Reagent Strip = LE and/or Nit detected Ducharme. 2007. Can J Emerg Med 9:87-92

  18. How Useful is the UA? Presence of bacteriuria in Different Asymptomatic Populations Nicolle. 2006. Int J Antimicrob Agent 28S:S42-S48

  19. When to Collect a Urine Specimen • 84 y patient from nursing home admitted to hospital with 3 d hx of confusion and dehydration • PMH includes heart diseaseand pneumonia • Clinical findings include: • Confusion, unable to answer questions • No fever or leukocytosis • Urine is cloudy • UA shows squam’s, protein, 1+ LE, casts, bacteria • Urine and blood specimens sent for culture • R/O pneumonia and UTI • Antibiotics administered • Culture • 1,000-10,000 CFU/ml Klesiellapneumoniae

  20. Consequences of Misreporting or Misinterpreting Urine Culture Results • Adverse drug reactions • Selection for infection with drug-resistant bacteria • C. difficileinfection • In-Patient Urine Cultures Ordered without Indication • 68/112 (68%) no clinical indication • Confusion, unexplained leukocytosis, previous hx UTI, abnormal smell or color of urine, recent catheterization, weakness or dizziness • 21/68 urine cultures were positive (contamination or ASB) • 12/21 received antimicrobial therapy that was not needed • Most urines were midstream not catheterized samples • Conclusion: Do not report culture results of midstream urines from hospitalized in-patients Leis at al. 2013. InfContr Hosp Epidemiol. 34:1113-14

  21. Consequences of Misreporting or Misinterpreting Urine Culture Results • Under Illinois law, Healthcare Facilities (hospitals, ambulatory services, and residential facilities) are required to report staph infections (MRSAs), c. difficile (CDIs), central line associated bloodstream infections (CLABSIs), ventilator associated pneumonia (VAPs), and surgical site infections (SSIs). • The law requires such healthcare facilities to make quarterly reports to the Illinois Department of Public Health. They, in turn, will publish the reports on their website annually. • Healthcare facilities report CLABSIs and SSIs to the NHSN. • If they do not comply, hospital licenses may be revoked.

  22. Consequences of Misreporting or Misinterpreting Urine Culture Results Illinois Hospital Report Card

  23. Catch Our Breath and Summarize • Urine cultures are not ordered for the correct clinical reasons • Urine cultures are frequently contaminated during collection • Asymptomatic bacteriuria is common, rarely needs to be treated and is accompanied by pyuria 50% of the time • UA is a poor screening test for infection • Laboratories do not have enough clinical information to report urine results correctly • Clinicians do not interpret urine culture reports correctly • Catheter-associated and nosocomial urinary tract infections are/will be reported to the IDPH for public display

  24. Catch Our Breath and Summarize WHAT A MESS! And, Urine Culture is the most common microbiology culture request the we get!

  25. What Can the Laboratory Do? • Work with infectious diseases, infection control and key hospital units to restrict urine culture • ICU, surgery, hospitalists • Educate care givers about midstream collection and the use of “straight-catheter” collection for infection diagnosis • Midstream v clean-catch midstream • Limit reporting of “bacteria” in UA • No report • 3-4+ only • Use stained smear • Use of the Gram stain for in-patients • Refrigerate urine (24 h to 1 wk) • Provide interpretations

  26. What Can the Laboratory Do? • Report only > 100,000 CFU/ml for “nosocomial” urines (> 2 days in hospital) • Use EMR to identify in-patients who qualify Kwon et al. 2012. Am J ClinPathol 137:778-784

  27. What Can the Laboratory Do? • New Urine Culture test codes • OP midstream (low counts when LE positive) • Straight-Cath or Suprapubic (low counts and unusual pathogens when LE positive) • In-patient midstream (high counts only) • Indwelling Catheter (avoid culture, list isolates, ID-only) • Urology Cystoscopy (surgical specimens, low counts, anaerobic culture) • Limit reporting of positive urines • In-patient midstream urines • Indwelling catheter urines

  28. Urine Cultures • Challenge for Most of Us! • “Ordering” and “Collection” Education • Key targets (ED, ICU) • Infection Control, Infectious Diseases, Urology • New urine culture test codes • Lab Interpretative Criteria based on Test Code • Don’t report all growth • Don’t report results for Indwelling Catheter and Nosocomial Midstream specimens • Lock your door

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